Necrotizing Enterocolitis as a Possible Manifestaion of Multisystem Inflammatory Syndrome in Neonates Related to SARS-CoV-2

Abstract

Background: Multisystem inflammatory syndrome in neonates (MIS-N) is hypothesized to be caused either following transplacental transfer of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) antibodies or antibodies developed in the neonate after infection with SARS-CoV-2. The common clinical manifestations include fever, respiratory distress, shock, and encephalopathy. Gastrointestinal manifestations include vomiting, diarrhea, bloody stools, and gastric residues. Necrotizing enterocolitis (NEC) has not been described before in MIS-N. Clinical Description: We report a term neonate presenting on day 10 of life with 2 days history of fever, abdominal distension, vomiting, reduced feeding, and not passing stool. He had tachycardia, tachypnea, a distended tense and tender abdomen with absent bowel sounds, and excessive irritability. Salient investigation results were anemia, neutrophilic leukocytosis, hyponatremia, metabolic acidosis, and elevated inflammatory markers. Dilated bowel loops on abdominal radiograph and thickening of bowel wall on abdominal ultrasonography were consistent with NEC. In view of the unusual presentation of NEC, the elevated biomarkers and setting of the pandemic, MIS-N was suspected, investigated, and the diagnostic criteria were found to be satisfied. Management: The baby received supportive care. Methylprednisolone, intravenous immunoglobulin, aspirin, and enoxaparin were started resulting in defervescence and decline in inflammatory markers. However, he developed fixed bowel loops and underwent an exploratory laparotomy. This revealed stricture and extensive necrosis of the terminal ileum with adhesive obstruction. The affected segment was excised, and loop ileo-colostomy was done. He gradually improved and was discharged on the 11th postoperative day on enteral feeds. The infant was thriving on follow-up. Conclusion: NEC may be a possible manifestation of MIS-N.